- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $1,202.26 / $2,754.23
| Professional | | $323.59 | $1,202.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $602.56 / $1,862.09
| Professional | | $257.04 | $602.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $794.33 / $3,548.13
| Professional | | $218.78 | $794.33 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,202.26 / $3,162.28
| Professional | | $346.74 | $1,202.26 | $3,162.28 |